Student Member Certification Worksheet

Complete this worksheet indicating the type of supporting document reviewed to verify age and enrollment of each
student member. Submit information via MyLCI and retain this form for club records. A copy of this form may be
requested by Lions Clubs International for required verification purposes.

Lions Club Name

Lions Club Number District

Member Status: New Member Existing Member Member Number (If existing):

Gender Date of Birth (month/day/year) (Required)

First (Given) Name Last (Family) Name

*Email

Check the box to indicate student member’s age and complete the corresponding information for your club’s records.

Student through age 30 (Joining any Lions club type)

School Name Anticipated Graduation Date (month/day/year)

Proof of enrollment: ID CS TR BL OT
Proof of age: DR SC BC PP OT (Check all that apply. Use key code below)
Students through age 30 joining a Lions club receive a charter/entrance fee waiver and pay only half international dues.

Student over age 30 (Joining a Campus Lions club)

School Name Anticipated Graduation Date (month/day/year)

Proof of enrollment: ID CS TR BL OT
Proof of age: DR SC BC PP OT (Check all that apply. Use key code below)
Students over age 30 and joining a Campus Lions club pay a reduced charter/entrance fee of USD$10.00 and full international
dues of USD$43.00.

Student Certification: The following information should be reviewed to verify eligibility for the Student Membership Program.

Proof of Enrollment Key Code: (ID) Student Identification Card - (CS) Class Schedule - (TR) Transcript - (BL) Bill - (OT) Other

Verification of Age Key Code: (DR) Driver’s License - (SC) State Identification Card - (BC) Birth Certificate - (PP) Passport - (OT) Other
For the purpose of Lions Clubs International Student Member Program dues provision, eligible members are as follows:

1. Student through age 30 (Joining any Lions club type)

Students are individuals enrolled in an educational institution and between the age of legal majority and through age 30 joining any type of Lions club.
Students are eligible to receive a charter/entrance fee waiver and pay only half international dues, through age 30.

Students of new Campus Lions clubs, or clubs with a majority of student members, are required to prepay one year of international dues and submit
with the charter application.

2. Student Over Age 30 (Joining a Campus Club)

Students over age 30 and joining a Campus Lions club pay a reduced entrance/charter fee of US$10. Regular international
dues apply.

Lions Club International Dues Structure

International Dues
Member Entrance Fee
Beginning July 1, 2013

Students through the age of 30 USD$0 USD$21.50

Students over age 30

USD$10 USD$43
(Joining a Campus Lions club)

Non-student faculty, staff, alumni,

USD$35 USD$43
community members, etc.

Charter club, send information via MyLCI or to: Existing club, send information via MyLCI or to:
Member Service Center/New Clubs Member Service Center
Lions Clubs International Lions Clubs International
300 W. 22nd Street 300 W. 22nd Street
Oak Brook, IL 60523 USA Oak Brook, IL 60523 USA
Fax: 630-203-3788 Fax: 630-203-3788
E-mail: newclubs@lionsclubs.org E-mail: memberservicecenter@lionsclubs.org

Lions Clubs International

300 W. 22nd St.
Oak Brook IL 60523-8842 USA
www.lionsclubs.org STU5 2/21 EN